Symptomatic Rheumatic Mitral Stenosis Research Articles

Impact of commissural calcification on clinical outcome of percutaneous balloon mitral valvuloplasty; a retrospective cohort study of 876 patients

BackgroundPercutaneous balloon mitral valvuloplasty (PBMV) is the ACC/AHA class I recommendation for treating symptomatic rheumatic mitral stenosis with suitable valve morphology, less than moderate MR and absence of left atrium clot. The mitral valve restenosis and significant mitral regurgitation (MR) are known adverse outcomes of PBMV. This study aimed to evaluate the outcomes of PBMV in patients with severe mitral stenosis and the effect of Commissural Calcification (CC) on the outcomes.MethodsIn this single-center retrospective cohort study, 876 patients who underwent PBMV were categorized into three groups based on their Wilkins score (Group I: score ≤ 8, Group II: score 9–10, and Group III: score 11–12). Patients were evaluated before, early after PBMV and at 6- and 24-month follow-ups. Main clinical outcomes were defined as significant restenosis and or symptomatic significant MR (moderate to severe and severe MR) or candidate for mitral valve replacement (MVR). The outcomes were compared between patients with and without CC.ResultsA total of 876 patients with mean age 46.4 ± 12.3 years (81.0% females) were categorized based on Wilkins score. 333 (38.0%) were in Group I, 501 (57.2%) were in Group II, and 42 (4.8%) were in Group III. CC was present in 175 (20.0%) of the patients, among whom 95 (54.3%) had calcification of the anterolateral commissure, 64 (36.6%) had calcification of the posteromedial commissure, and in 16 (9.1%) patients both commissures were calcified. There was a significant difference in Wilkins score between patients with and without CC (P < 0.001). CC was associated with higher odds of significant symptomatic MR at early and mid-term follow up (OR: 1.69, 95%CI 1.19–2.41, P = 0.003; and OR: 3.90, 95%CI 2.61–5.83, P < 0.001, respectively), but not with restenosis (P = 0.128). Wilkins Groups II and III did not show higher odds of significant symptomatic MR compared to Group I at early (II: P = 0.784; III: P = 0.098) and mid-term follow up (II: P = 0.216; III: P = 0.227). Patients in Wilkins Group II had higher odds of restenosis compared to Group I (OR: 2.96,95%CI: 1.35–6.27, P = 0.007).ConclusionCommissural calcification (CC) is an independent predictor of the significant symptomatic MR (an important determinant of adverse outcome) following PBMV in the early and mid-term follow-up. Mitral valve restenosis occurs more in patients with higher Wilkins score compared to group I with score ≤ 8. Combined Wilkins score and CC should be considered for patient suitability for PBMV.

Impact of post-percutaneous mitral balloon valvuloplasty mitral valve area indexed for the body size on long-term outcomes in rheumatic mitral stenosis: a 20-year retrospective analysis

Abstract Introduction Percutaneous mitral balloon valvuloplasty (PBMV) remains one of the standard treatments for symptomatic rheumatic mitral stenosis (MS)(1). The procedural success criteria are generally defined as a post-procedural mitral valve area (MVA) of more than 1.5 cm2 without significant mitral regurgitation or in-hospital complications(2, 3). However, the effect of body size on the post-procedural MVA is not well examined. Purpose This study intended to investigate the association between the different methods of indexing post-PBMV MVA for the body size parameters and event-free survival compared to the absolute MVA in rheumatic MS patients treated with PBMV. Methods We retrospectively enrolled clinically significant rheumatic MS patients (MVA ≤1.5 cm2) who underwent PBMV with Inoue balloon between June 2002 and February 2021. The patients who experienced in-hospital complications (stroke, emergency surgery, or death) were excluded. A final number of 584 out of 618 patients were included in the analysis. Post-procedural MVA was assessed using echocardiographic 2D planimetry or pressure half-time if planimetry was not available. Post-PBMV MVA was indexed by body surface area (BSA), body mass index (BMI), body weight or height. The median value of absolute MVA and indexed MVA was used to stratify patients into two groups. The primary outcome was the composite of death, repeat PBMV, and mitral valve surgery. We performed Cox regression analyses to assess the association between groups and outcomes. C-index was calculated to assess the discriminative ability of each index. Results The mean age was 41.5 (±11.9) years, and 490 patients (82.8%) were female. The prevalence of atrial fibrillation was 39.5%. The median Wilkin score was 8 (interquartile range of 7-9). The mean pre-procedural and post-procedural MVA was 0.92 (±0.24) and 1.57 (±0.28) cm2, respectively. The average pre-procedural and post-procedural mean pressure gradient was 13.1 (±6.3) and 5.7 (±3.0) mmHg, respectively. The prevalence of post-procedural MR in a moderately severe to a severe degree was 3.8%. Over a median follow-up of 3.9 years, 194 composite events occurred. Patients with post-procedural indexed MVA of any type greater than a median were not associated with a significantly lower risk of primary outcome compared to those with indexed MVA less than the median (Picture 1). Moreover, absolute MVA greater than a median (1.55 cm2) was independently associated with a lower risk of primary outcome after adjusting with age and gender (Hazard ratio [95% CI] = 0.658 [0.493-0.879], p = 0.005). The discriminative ability of the absolute MVA was highest than the indexed MVA (Picture 2). Conclusion Indexing post-procedural MVA did not provide additional benefit on long-term risk stratification after PBMV compared with the absolute MVA.

Three-dimensional Echocardiography during Percutaneous Mitral Balloon Valvuloplasty

Percutaneous mitral balloon valvuloplasty (PMBV) has been frequently used as an alternative to open or closed surgical mitral commissurotomy for the treatment of selected patients with symptomatic rheumatic mitral stenosis. PMBV has been proven a safe and effective method, often performed under fluoroscopic guidance. With the advent of three-dimensional echocardiography (3DE), interventional cardiologists have been able to successfully perform complex procedures such as paravalvular leak closure, transcatheter edge-to-edge repair of the mitral valve (MV) using MitraClip, etc. With the expertise derived from these procedures, 3DE has received considerable interests in many other procedures, including PMBV. Pre-, intra-, and postprocedural assessments of the mitral valve (MV) area; commissural splitting; the presence, degree, and location of mitral regurgitation; and other procedure-related complications can be more accurately and readily made using 3DE. In addition, real-time 3D transesophageal echocardiography has been proven to be more accurate than two-dimensional (2D) techniques in identifying specific MV abnormalities associated with complex diseases. Moreover, real-time 3DE offers the advantage of shorter fluoroscopy and radiation times throughout PMBV. This article reviews the use of 3DE during PMBV in light of the most recent literature and based on expertise and discusses the pros and cons of 3DE, with emphasis on its superiority to conventional 2D echocardiography.

Systemic Immune Inflammation-Index and CANLPH Score in Patients with Mitral Stenosis Undergoing Balloon Valvuloplasty

Objective: to evaluate CANLPH score and systemic immune inflammation index (SII) in patients with symptomatic rheumatic mitral stenosis (MS) undergoing percutaneous mitral balloon valvuloplasty (PMBV). Methods: 62 patients who underwent PMBV in our clinic between 2018 and 2021 were included retrospectively. The patients were divided into 2 groups according to echo score. The CANLPH score was calculated from the cut-off values of C-reactive protein to albumin ratio (CAR), neutrophil to lymphocyte ratio (NLR) and platelet to hemoglobin ratio (PHR), determined with the Youden index and SII by the formula platelet x neutrophil/lymphocyte. P &lt;0.05 was considered statistically significant. Results: The mean age of the patients was 44.5±10.4 years (40 female, 64.5%). The mean values of SII and CANLPH scores were higher in the Echo score &gt;8 group (p &lt;0.001, both). The mean mitral gradient before and after PMBV was 12.6±5.7mm Hg and 5.0±2.4 mm Hg, and the mean valve area was 1.12±0.27 cm2 and 1.85±0.29 cm2. A statistically significant and negative correlation was observed between the gradient decrease after the procedure and the CANLPH score and SII (r=-0.426, p=0.001 and r=-0.418, p=0.001, respectively). In receiver operating characteristic (ROC) curve analysis, it was concluded that the ability of CANPLH score to predict the higher Echo scores was noninferior to SII with an area under curve (AUC:0.820 (0.701-0.906) and AUC:0.786 (0.664-0.880), z statistics 0.576 and p=0.564. Conclusion: SII and CANLPH scores are correlated with Echo score. A significant negative relationship was found with both biomarkers and gradient decrease after the PMBV.

Immediate maternal and fetal outcome following percutaneous mitral valve balloon commissurotomy: a 6-year single-center experience from sub-Saharan Africa.

Mitral stenosis is the most common valvular heart disease during pregnancy. When severe, it leads to significant maternal and fetal morbidity and mortality. Percutaneous mitral valve balloon commissurotomy can be performed during pregnancy, and the present study aimed to describe the immediate maternal and fetal outcomes after percutaneous mitral valve balloon commissurotomy was done in a cohort of 23 pregnant patients with severe mitral stenosis in Addis Ababa, Ethiopia. Included in the current study were all pregnant mothers who had severe rheumatic mitral valve stenosis and who underwent percutaneous mitral valve balloon commissurotomy at the Cardiac Center of Ethiopia over 6-year period. Data were collected through chart abstraction using a structured proforma and then analysed using STATA version 13.0. Median gestational age was 22 weeks and percutaneous mitral valve balloon commissurotomy was successful resulting in a significant increase in the mean mitral valve area of the group from 0.78 ± 0.20 cm2 to 1.89 ± 0.31 cm2 (p < 0.001). The mean mitral valve inflow gradient of the group was 23.95 ± 6.27 mmHg and 6.80 ± 2.44 mmHg, respectively, before and after the percutaneous mitral valve balloon commissurotomy procedure (p < 0.001). Post-procedure, there was no significant increment in mitral valve incompetence. The mean pulmonary artery pressure of the group decreased from 77.68 ± 23.19 mmHg to 42.31 ± 9.95 mmHg (p < 0.001). There was no fetal or maternal death following the procedure. Pregnancy ended at term gestation for 19/23 (82.6%) of the mothers and the mean birth weight of the neonates was 2800 g. Percutaneous mitral valve balloon commissurotomy procedure can safely be done for severe symptomatic rheumatic mitral stenosis in pregnancy in our setting.

Association of atrial strain ratio with invasive pulmonary hemodynamics in rheumatic mitral stenosis

Abstract Funding Acknowledgements Type of funding sources: None. Background. Symptomatic rheumatic mitral stenosis (MS) results in elevation in left atrial (LA) pressure that is passively transmitted to derange pulmonary hemodynamics and subsequently elevate right ventricular afterload. We studied associations between LA to right atrial reservoir strain ratio (LA-RAs) and invasive pulmonary hemodynamics in addition to the ratio’s ability to identify subjects with elevated pulmonary vascular resistance (PVR). Methods. Consecutive MS subjects undergoing right heart catheterization (RHC) and percutaneous transvenous mitral commissurotomy (PTMC) were enrolled. Subjects with atrial fibrillation, &amp;gt;mild mitral regurgitation, concomitant aortic valve or ischemic heart disease were excluded. LA-RAs was assessed by speckle-tracking echocardiography and stratified into high or low LA-RAs subgroups based on mean value. Correlations with invasive pulmonary hemodynamics was studied. ROC analysis was performed to identify pulmonary hypertension (PH) and PVR &amp;gt; 3 Wood Units. Results. 110 subjects were analysed (age: 32 ± 8; 72% female). LA and RA reservoir strain was feasible in 88 (80%) and 83 (75%) subjects respectively. Patients with low LA-RAs demonstrated more severe MS (0.8 ± 0.1 vs. 1.0 ± 0.2cm2), higher mean pulmonary artery (43 ± 13 vs. 33 ± 13mmHg) and capillary wedge pressure (28 ± 6 vs.23 ± 16mmHg) as compared with high LA-RAs (p &amp;lt; 0.001 for all). LA-RAs was associated with invasive PA systolic (r=-0.30;p = 0.05), diastolic (r=-0.28;p = 0.02) and mean (r=-0.33; p = 0.002) pressures, demonstrated modest ability to identify elevated PVR (AUC = 0.65;p = 0.03) and strong ability to identify PH (AUC = 0.75; p &amp;lt; 0.001). LA-RAs significantly increased after PTMC (0.43 ± 0.1 to 0.52 ± 0.1;p &amp;lt; 0.001). Conclusions. The novel atrial strain ratio is associated with measures of invasive pulmonary hemodynamics and demonstrates ability to identify PH and elevated PVR in MS.

Percutaneous mitral balloon valvuloplasty - state of the art

Since its introduction in 1982, percutaneous mitral balloon valvuloplasty (PMV) has been used successfully as an alternative to open or closed surgical mitral commissurotomy in the treatment of patients with symptomatic rheumatic mitral stenosis. PMV is safe and effective and provides sustained clinical and hemodynamic improvement in patients with mitral stenosis. The immediate and long-term results appear to be similar to those of surgical mitral commissurotomy. Proper patient selection is an essential step for being able to predict the immediate results of PMV. Candidates for PMV require precise assessment of the mitral valve morphology. The Wilkin’s echocardiographic score (Echo-Sc) is currently the most widely used method for predicting PMV outcome. Leaflet mobility, leaflet thickening, valvular calcification, and sub valvular disease are each scored from 1 to 4. An inverse relationship exists between the Echo-Sc and PMV success. Both immediate and intermediate follow-up studies have shown that patients with Echo-Sc ≤ 8 have superior results, significantly greater survival, and event free survival compared to patients with Echo-Sc &gt; 8. We identified other clinical and morphologic predictors of PMV success that include age, pre-PMV mitral valve area, history of previous surgical commissurotomy, and mitral regurgitation (MR), and post-PMV variables (e.g., post-PMV MR ≥ 3 + and pulmonary artery pressure), that may be used in conjunction with the Echo-Sc to optimally identify candidates for PMV. This concept demonstrates a multifactorial nature of the prediction of immediate and long-term results. Other echocardiographic scores have been developed for the screening of potential candidates for PMV. They include a unique score that take into account the length of the chordae. A novel quantitative score that included the ratio of the commissural areas over the maximal excursion of the leaflets from the annulus in diastole. The components of this score include mitral valve area ≤ 1 cm2, maximum leaflet displacement ≤ 12 mm, commissural area ratio ≥ 1.25, and sub valvular involvement. Finally, a score that is able to identify patients who are more likely to develop significant mitral regurgitation post-PMV. This score takes into account the distribution (even or uneven) of leaflet thickening and calcification, the degree and symmetry of commissural disease, and the severity of subvalvular disease. The transvenous transseptal approach is the most widely used PMV technique. The two major techniques of PMV are the double-balloon technique and the Inoue technique which are equally effective techniques of PMV. Encouraging results of PMV have been reported in special mitral stenosis population cohorts including pregnant women, patients with previous surgical commissurotomy, patients with atrial fibrillation, patients with pulmonary hypertension, elderly patients, patients with calcific mitral stenosis, and patients with associated aortic regurgitation. To summarize, PMV is the preferred form of therapy for relief of mitral stenosis for a selected group of patients with symptomatic mitral stenosis and suitable valve anatomy for valvuloplasty. Patients with Echo-Sc ≤ 8 have the best results, particularly if they are young, are in normal sinus rhythm, have no pulmonary hypertension, and have no evidence of calcification of the mitral valve under fluoroscopy. The immediate and long-term results of PMV in this group of patients are similar to those reported after surgical mitral commissurotomy. Patients with Echo-Sc &gt; 8 have only a 50% chance to obtain a successful hemodynamic result with PMV, and the long-term follow-up results are worse than those from patients with Echo-Sc ≤ 8. In patients with Echo-Sc ≥ 12, it is unlikely that PMV could produce good immediate or long-term results and they preferably should undergo mitral valve replacement. However, PMV could be considered in these patients if they are high-risk or unqualified surgical candidates.

Novel Prognostic Score for Immediate and Late Success After Percutaneous Mitral Balloon Commissurotomy in Patients With Mitral Stenosis.

Percutaneous mitral balloon commissurotomy (PMBC) remains the preferred treatment for patients with severe symptomatic rheumatic mitral stenosis (MS) and suitable anatomy. The objective of this study was to propose a new score for the prediction of immediate and late success. This is a single-center, retrospective analysis of all 1582 patients with severe mitral stenosis who underwent PMBC from August 1987 to July 2010. The composite outcome was cardiovascular death, new PMBC, or mitral valve repair surgery up to 24 years of follow-up. Mean patient age was 36.8 ± 12.9 years, most (86.4%) were female, and Wilkins score was between 9-11 in 49.1% of patients. In the multivariate analysis, the predictors of immediate success were age (odds ratio [OR], 0.98; 95% confidence interval [CI], 0.96-0.99; P=.01), left atrium size (OR, 0.96; 95% CI, 0.93-0.99; P=.01), mean preprocedure mitral gradient (OR, 0.93; 95% CI, 0.89-0.96; P<.001), intermediate Wilkins score 9-11 (OR, 0.62; 95% CI, 0.40-0.94; P=.02), and high Wilkins score ≥12 (OR, 0.35; 95% CI, 0.16-0.76; P<.01). For prediction of late events, age (hazard ratio [HR], 0.98; 95% CI, 0.97-0.98; P<.001), New York Heart Association class III-IV (HR, 1.50; 95% CI, 1.18-1.92; P<.001), left atrium size (HR, 1.02; 95% CI, 1.02-0.04; P<.01), and high Wilkins score ≥12 (HR, 2.02; 95% CI, 1.30-3.15; P<.01) were significant. Two nomograms were developed using significant predictors from the model. In this large population, not only the Wilkins score, but also clinical and hemodynamic features, seem to be relevant in predicting immediate and late success for patients with rheumatic MS who underwent PMBC.

Perioperative myocardial infarction in a case of mitral valve replacement: Rare complication of a common procedure

A 56-year-old female underwent mitral valve replacement for severe symptomatic rheumatic mitral stenosis. There was perioperative myocardial infarction as evidenced by the regional echocardiogram (ECG) and echocardiographic changes (left anterior descending [LAD] territory) and hemodynamic instability. The patient was immediately taken up for coronary angiogram to find complete occlusion of mid-segment of the LAD artery. Thrombus aspiration and intracoronary nitrates were given to restore thrombolysis in myocardial infarction (TIMI) III flow in the vessel. The patient was discharged after 10 days without any other complications. On follow-up ECG, the regional wall motion abnormality persisted. Repeat coronary angiogram done for the same revealed no lesions in coronary vessels with TIMI III flow.

TCT-801 Predictors of Immediate Success and Long-Term Clinical Outcomes After Percutaneous Mitral Balloon Valvuloplasty in Patients With Rheumatic Mitral Stenosis

Percutaneous mitral balloon valvuloplasty (PMBV) still remains as the preferred treatment for patients with severe symptomatic rheumatic mitral stenosis and suitable anatomy. This study sought to access the immediate and very long-term outcomes after successful PMBV. This is a single-center

Very Long Term Follow-Up After Percutaneous Balloon Mitral Valvuloplasty

ObjectivesThe aim of this study was to assess very long term outcomes after successful percutaneous balloon mitral valvuloplasty (PBMV). BackgroundPBMV remains the preferred treatment for patients with severe symptomatic rheumatic mitral stenosis and suitable anatomy. MethodsAll consecutive patients who underwent successful PBMV between 1987 and 2010 were included. The primary endpoint was the composite of all-cause mortality, need for mitral surgery, or repeat PBMV up to 23 years. ResultsAmong all 1,582 consecutive patients undergoing PBMV, acute success was achieved in 90.9% (n = 1,438). Independent predictors of acute success included left atrial size (odds ratio: 0.96; 95% confidence interval [CI]: 0.93 to 0.99; p = 0.045), Wilkins score ≤8 (odds ratio: 1.66; 95% CI: 0.48 to 0.93; p = 0.02) and age (odds ratio: 0.97; 95% CI: 0.96 to 0.99; p = 0.006). Very long term follow-up (median 8.3 years, mean 15.6 years) was obtained in 79.1% of successful cases. The incidence of the primary endpoint was 19.1% (95% CI: 17.0% to 21.1%). The rates of overall mortality, need for mitral valve surgery, or repeat PBMV were 0.6% (95% CI: 0.3% to 1.2%), 8.3% (95% CI: 7.0% to 9.9%), and 10.0% (95% CI: 8.5% to 11.7%), respectively. On multivariate analysis, New York Heart Association functional class III or IV (hazard ratio: 1.62; 95% CI: 1.26 to 2.09; p < 0.001), higher age (hazard ratio: 0.97; 95% CI: 0.96 to 0.98; p = 0.028), and mitral valve area ≤1.75 cm2 after the procedure (hazard ratio: 1.67; 95% CI: 1.28 to 2.11; p = 0.028) were independent predictors of the primary endpoint. ConclusionsIn very long term follow-up, more than 75% of patients exhibited sustained results. Prediction of late favorable results is multifactorial and strongly determined by age, previous symptoms and post-procedural mitral valve area.

TCT-628 Very Long-Term (Up To 23 Years) Follow-Up After Successful Mitral Balloon Valvuloplasty In A Large Series Of Patients With Rheumatic Mitral Stenosis

Introduction: Although there has been a steady decline in the incidence of rheumatic heart disease, rheumatic mitral stenosis still causes significant morbi-mortality worldwide. Percutaneous mitral balloon valvuloplasty (PMBV) remains as the preferred treatment option for patients with suitable anatomy and severe symptomatic rheumatic mitral stenosis. Hypothesis: We sought to assess the very long-term outcomes after successful PMBV. Methods: This is a single center analysis of all consecutive patients who underwent successful PBMV (post-procedural valve area ≥ 1.5 cm 2 and regurgitation moderate or less, without in-hospital major adverse cardiac and cerebrovascular events) between 1988 and 2011. The primary endpoint was to determine the incidence of major adverse cardiac events (MACE), including global death and need for mitral surgery or repeat PMBV up to 23 year after the procedure. Results: Among all 1577 patients, the success rate was achieved in 91.3% (1140 patients). The predictors of success were NYHA functional class III-IV (hazard ratio [HR]: 1.73, 95% CI: 1.15-2.60, p=0.008) and Wilkins-score Conclusions: Up to 23 years after successful PMBV, a sizeable proportion of patients still exhibit sustained results after PMBV.

Transjugular balloon mitral valvotomy in a patient with severe kyphoscoliosis

Balloon mitral valvotomy (BMV) performed by the conventional transfemoral approach can be difficult or even impossible in the presence of structural impediments such as severe kyphoscoliosis, gross cardiac anatomic distortion and inferior vena caval anomalies. A 25-year-old woman with severe thoracolumbar kyphoscoliosis due to poliomyelitis presented with symptomatic rheumatic mitral valve stenosis. After the failure of transfemoral BMV, the procedure was attempted from the right jugular access, using a modified septal puncture technique. The left atrium was entered from the jugular access and the mitral valve was crossed and dilated successfully using over the wire balloon technique. Transjugular BMV is an effective alternative in patients with kyphoscoliotic spine that preclude transfemoral approach. The detailed technique used for the procedure, its advantages as well as the other percutaneous treatment options are also discussed.

0359: Percutaneous balloon mitral commissurotomy in children and young adults with rheumatic mitral stenosis

To determine the efficacy and the safety of percutaneous balloonmitral commissurotomy (PBMC) in young patients (aged under 18 years – olds) with rheumatic mitral stenosis and to compare these results with those of adult patients. Percutaneous transvenous mitral commissurotomy (PTMC) using the Inoue technique was performed in 480 patients with rheumatic mitral stenosisbetween 1998 and 2013. 41 were aged under 18 years – old (group 1). The other 439 patients (group 2) had a mean age of 34±11.9 years. All patients were assessed clinically. An echocardiography was performed before and after the procedure. Mean age in group 1 was 15±2.95 years (range 8 to 18) with a women predominance (73.2% vs. 26.8%.). In group 1, there was a significant increase of the mean mitral valve area index (MVAI) (0.84±0.24 vs 1.78±0.39cm 2 , p <0.001), a significant reduction of the mean transmitral pressure gradient (21.78±6.62to8.75±5.87 mm Hg, p <0.001) and of the mean left atrial pressure (28.46±7.59to12.87±5.57 mmHg, p < 0,001) from pre- to post-PBMC, respectively. Mild mitral regurgitation developed in 12 and moderate mitral regurgitation developed in 3 patients.The mean follow-up was 92±40 months. Improvement in symptomatic status by at least one NYHA class was seen in the majority of patients.A good result during the follow up was observed in 46.3% of controlled patients and restenosis in 53.7% of cases with an average of 46±34 months. The immediate hemodynamic results in children were compared to 439 adult patients who underwent PBMC in the same period. The outcome was similar in both groups. Children were found to have significantly higher rate of mitral restenosis compared to adults (53.7% vs. 31.9%). Despite a high rate of restenosis, PBMC is very effective and safe in children, and consider that it should be the procedure of choice for young patients with symptomatic rheumatic mitral stenosis.

The Impact of Right Ventricular Stroke Work on B‐Type Natriuretic Peptide Levels in Patients With Mitral Stenosis Undergoing Percutaneous Mitral Valvuloplasty

We aimed to explore the relationship between brain natriuretic peptide (BNP) levels and right ventricular (RV) function in patients with mitral stenosis (MS), and to investigate the hemodynamic parameters that predict reduction of BNP levels after percutaneous mitral valvuloplasty (PMV). Few studies have evaluated BNP in the context of MS, specifically the impact of the RV stroke work (RVSW) on serum BNP levels has not been defined. Thirty patients with symptomatic rheumatic MS in sinus rhythm who were referred for a PMV were enrolled. Right and left heart pressures were obtained before and after valvuloplasty. RVSW index (RVSWI) was calculated by cardiac catheterization. Basal BNP levels were elevated in MS patients and correlated with several hemodynamic parameters including pulmonary pressure, pulmonary vascular resistance index, cardiac index (CI), and RVSWI. In multivariate analysis, CI and RVSWI were independent predictors of raised basal BNP levels. PMV resulted in a significant decrease in the RVSWI with a concurrent increase in CI (2.4 ± 0.43 to 2.9 ± 0.8 L/min/m(2), P = 0.010). Overall, plasma BNP levels significantly decreased from 124 (63/234) to 73 (48/148) pg/ml postvalvuloplasty. Multivariate analysis revealed that the reduction of left atrial (LA) pressure post-PMV was an independent predictor of change in BNP levels. Elevated baseline BNP level in MS patients was independently associated with CI and RVSWI. Plasma BNP levels were reduced after successful PMV, which was associated with the reduction of the LA pressure.

Assessment of mitral valve commissural morphology by transoesophageal echocardiography predicts outcome after balloon mitral valvotomy

Balloon mitral valvotomy (BMV) is a safe and an effective treatment in patients with symptomatic rheumatic mitral stenosis. This study was conducted to validate the importance of assessing the morphology of mitral valve commissures by transoesophageal echocardiography and thereby predicting the outcome after balloon mitral valvotomy [BMV]. Study consisted of 100 patients with symptomatic mitral stenosis undergoing BMV. The Commissural Morphology and Wilkins score were assessed by transoesophageal echocardiography. Both the commissures (anterolateral and posteromedial) were scored individually according to whether non-calcified fusion was absent (0), partial (1), or extensive (2) and calcification (score 0) and combined giving an overall commissural score of 0-4. Outcome of BMV was correlated with commissural score and Wilkins score. The commissural score and outcome after BMV correlated significantly. 66 of 70 patients (94%) with a commissural score of 3-4 obtained a good outcome compared with only six (20%) patients of 30 with a commissural score of 0-2 (positive and negative predictive accuracy 94% and 80%, respectively, p < 0.001). Increase in 2DMVA post BMV was more in patients with higher commissural score (score of 3-4). Wilkins score <8 usually predicts a good outcome but even in patients with Wilkins score >8 a commissural score >2 predicts a 50% chance of a good result. A higher commissural score predicts a good outcome after BMV hence it can be concluded that along with Wilkins score, commissural morphology and score should be assessed with TOE in patients undergoing BMV.

A Novel Technique for Multi-Track Percutaneous Balloon Mitral Valvoplasty

Percutaneous balloon mitral valvoplasty (PBMV) has become the treatment of choice for severe pliable rheumatic mitral stenosis. The multi-track system is a recent variation of the double-balloon technique and is easier owing to the use of a monorail balloon and a simple, single-guidewire approach. In the present study, we used the double-coil Inoue metal wire with a multi-track balloon instead of the conventional multi-track wire. We studied 62 consecutive patients (55 females) with significant symptomatic rheumatic mitral valve stenosis who underwent multi-track PBMV. Patients were randomized into 2 groups: the first group included 32 patients treated with the novel multi-track technique using the double-coil Inoue metal wire, and the second group included 30 patients treated with the conventional multi-track technique using a balloon endhole catheter and multi-track 0.035 inch stiff wire. None of the patients had cardiac tamponade, systemic thromboembolism, or any groin complications. No statistically significant differences were found between the 2 groups regarding any of the studied variables. There were no in-hospital deaths or complications necessitating emergent cardiac surgery in either group. In conclusion, this new technique with the double-coil Inoue metal wire achieves the double benefit of being as safe as (and indeed easier than) the conventional technique, and it utilizes fewer materials, making the multi-track system more cost-effective.

Effect of percutaneous mitral balloon valvuloplasty on left atrial appendage function: Transesophageal echo study

BackgroundTo compare left atrial appendage (LAA) function by Doppler and Doppler tissue imaging (DTI) before and after percutaneous balloon mitral valvuloplasty (PBMV). Materials and methodsFifty-nine patients with symptomatic rheumatic mitral stenosis who underwent PBMV were included in this study. LAA function was measured before and after PBMV. To study LAA function, LAA late emptying (LAALE) velocity, LAA late filling (LAALF) velocity, and LAA area change percentage (LAAAC %) were measured. In the DTI study, tissue Doppler velocities of the LAA, including peak early diastolic (ELAA), peak late diastolic (ALAA), and peak systolic (SLAA), were measured. ResultsThere was significant increase in LAALE velocity, LAALF velocity, ELAA, ALAA, SLAA waves measured by Doppler and DTI after PBMV compared with baseline (p < 0.001) but there was no significant change in LAAAC% (p = not significant). Spontaneous echo contrast was present in 10 of the 59 patients before the procedure. It completely disappeared (6 patients) or decreased (4 patients) after PBMV. ConclusionsOur results suggest that PBMV improves LAA function and, thereby, may have a favorable influence on future thromboembolic complications.

Balloon mitral valvotomy in patients with mitral stenosis and left atrial thrombus

To evaluate the safety and efficacy of balloon mitral valvotomy (BMV) in symptomatic rheumatic mitral stenosis (MS) patients with left atrial (LA) thrombus and to address the technical issues. LA thrombus in patients with MS has long been regarded as a contraindication for BMV. There are few reports of BMV in presence of LA appendage (LAA) thrombus and reports of BMV in presence of LA body thrombus are still rare. 2,763 patients with suitable valve morphology were screened for BMV. 194 patients had LA/LAA thrombus and were put on adequate anticoagulation for 8-12 weeks. A total of 108 patients with persistent LA thrombus who satisfied the inclusion criteria (LA thrombus type Ia, Ib, and IIa) formed the study group and the remaining 2,622 patients who did not have any LA thrombus constituted the control group. All patients in the study group underwent BMV by modified over the wire technique. There was significant and comparable improvement in the mitral valve area, mitral valve gradient, LA mean and pulmonary artery systolic pressure following the procedure in both groups. In the study group, there were no thromboembolic episodes during the procedure. However, there was one case of transient ischemic attack in the study group which occurred 6 hr after a successful BMV. In the study group, one patient had cardiac tamponade needing aspiration and there was no in-hospital death. In selected patients of mitral stenosis with LA thrombus (type Ia, Ib, and IIa), BMV can be performed safely with the modified over the wire technique. Systemic thromboembolism, technical failures and other complications are very rare when performed by experienced operators.

Percutaneous balloon commissurotomy reduces incidence of ischemic cerebral stroke in patients with symptomatic rheumatic mitral stenosis

Whether percutaneous balloon commissurotomy reduces cerebral stroke in patients with symptomatic rheumatic mitral stenosis remains obscure. This study enrolled 170 such patients undergoing either medical therapy alone ( n = 71) or balloon commissurotomy ( n = 99). In the short term, balloon commissurotomy was successfully accomplished in 99% patients without embolic complications. At follow-up (mean 4.2 ± 3.2 years), patients undergoing commissurotomy encountered significantly rarer ischemic stroke than the medicine group (2% vs. 13%, p = 0.043). Multivariate Cox regression analysis further confirmed balloon commissurotomy as a negative predictor for ischemic stroke (hazard ratio 0.135, p = 0.011). These results lead to the conclusion that percutaneous balloon commissurotomy could substantially decrease the long-term incidence of ischemic cerebral stroke in eligible patients with symptomatic rheumatic mitral stenosis.